Single coronary artery Left (SCA L)-Right coronary artery arising from mid-left anterior descending coronary artery: New variant of Lipton classification (SCA L-II) diagnosed by computed tomographic angiography.

Isolated single coronary artery (SCA) is a rare anomaly. Current classification of left and right is further classified based on the course of the anomalous vessel. We report two SCA L cases where right coronary artery (RCA) arose from mid-left anterior descending coronary artery (LAD). Our observation is a variation from the current Lipton classification SCA L Type II where RCA arose from left coronary artery before the LAD, in our cases the RCA arose from mid LAD after the first septal perforator. We believe that this variant should be described as SCA L Type II variant 2 (V2) while the original Lipton classification should be described as SCA L Type II variant 1 (V1).

Real time three-dimensional transesophageal echocardiographic evaluation of aortic valve perforation.

OBJECTIVES: This study evaluated the feasibility of real time three-dimensional transesophageal echocardiography (RT3DTEE) in the diagnosis and localization of aortic valve perforation. METHODS: Aortic valve perforation was diagnosed in 12 patients by multiplane two-dimensional transesophageal echocardiography (2DTEE). We studied the feasibility of RT3DTEE using en face view in detection and precise localization of the aortic valve perforation. The artifactual dropout on RT3D images of aortic valve can mimic perforation and lead to a false positive diagnosis. We defined a true perforation as the hole with thicker margin and its visibility in both systole and diastole. We combined the RT3D images from 10 subjects with relatively normal aortic valve without perforation (test group) with the 12 with perforation for a blind review by an experienced echocardiographer. RESULTS: There were 14 perforations in 12 patients. The perforation was located in the left coronary cusp in 1, the noncoronary cusp in 7, and the right coronary cusp in 6 patients. In the subgroup of 9 patients with 11 perforations, all were confirmed at surgery. In test group the artifact mimicking perforation was frequently encountered (7/10 or 70%). However, they did not meet the criteria for true perforation except in 1 (1 false positive). All true perforations were correctly recognized. CONCLUSIONS: En face imaging with RT3DTEE can be used to confirm aortic valve perforation and its spatial location. However, RT3D should be used as an extension to comprehensive 2DTEE and color flow imaging.

Measuring cardiac index with a focused cardiac ultrasound examination in the ED.

OBJECTIVES: Noninvasive technology may assist the emergency department (ED) physician in determining the hemodynamic status in critically ill patients. The objective of our study was to show that ED physicians can accurately measure cardiac index (CI) by performing a bedside focused cardiac ultrasound examination. METHODS: A convenience sample of adult subjects were prospectively enrolled. Cardiac index, left ventricular outflow tract (LVOT) diameter, velocity time integral (VTI), stroke volume index, and heart rate were obtained by trained ED physicians and a certified cardiac sonographer. The primary outcome was percent of optimal LVOT diameter and VTI measurements as verified by an expert cardiologist. RESULTS: One hundred patients were enrolled, with obtainable CI measurements in 97 patients. Cardiac index, LVOT diameter, VTI, stroke volume index, and heart rate measurements by ED physician were 2.42 ± 0.70 L min(-1) m(-2), 2.07 ± 0.22 cm, 18.30 ± 3.71 cm, 32.34 ± 7.92 mL beat(-1) m(-2), and 75.32 ± 13.45 beats/min, respectively. Measurements of LVOT diameter by ED physicians and sonographer were optimal in 90.0% (95% confidence interval, 82.6%-94.5) and 91.3% (73.2%-97.6%) of patients, respectively. Optimal VTI measurements were obtained in 78.4% (69.2%-85.4%) and 78.3% (58.1%-90.3%) of patients, respectively. In 23 patients, the correlation (r) for CI between ED physician and sonographer was 0.82 (0.60-0.92), with bias and limits of agreement of -0.11 (-1.06 to 0.83) L min(-1) m(-2) and percent difference of 12.4% ± 10.1%. CONCLUSIONS: Emergency department ED physicians can accurately measure CI using standard bedside ultrasound. A focused ultrasound cardiac examination to derive CI has potential use in the management of critical ill patients in the ED.

Mitral annular geometry in normal and myxomatous mitral valves: three-dimensional transesophageal echocardiographic quantification.

BACKGROUND AND AIM OF THE STUDY: The mitral annulus (MA) has a complex dynamic geometry that is difficult to visualize in two dimensions; hence, novel real-time three-dimensional transesophageal echocardiography (RT-3D-TEE) provides insights into its dynamic nature. The study aim was to investigate changes in MA geometry in normal subjects and to explore differences in patients with myxomatous mitral valve disease (MMVD), using 3D quantitation with RT-3D-TEE. METHODS: Thirty-five participants (18 with MMVD, 17 normal subjects as controls) were enrolled into the study. The following geometric measurements were obtained at end-systole (ES) and end-diastole (ED): surface area, circumference, perimeter, height, commissure-to-commissure (C-C) diameter, anterior-to-posterior (A-P) diameter, and the ratio of A-P diameter to C-C diameter (circularization). To detect the effect of the severity of mitral regurgitation (MR) on MA dynamics, patients with MMVD were allocated to two subgroups with mild (n = 7) or moderate/severe (n = 11) MR. RESULTS: Control subjects demonstrated a saddle-shaped, elliptical MA configuration with slightly larger ES parameters. The MA shape was changed during the cardiac cycle, being more circular at ES and flatter at ED (p < 0.05). In MMVD patients, the MA retained a saddle shape but became dilated and circular with larger ED parameters compared to controls (p < 0.05). The degree of MA geometric changes was more prominent in moderate/severe MR patients (p < 0.001), while mild MR patients displayed MA geometry and dynamics similar to those of controls. CONCLUSION: The MA geometry is altered in MMVD patients, with the extent of changes being determined by the severity of the MR. RT-3D-TEE provides high-quality images that permit a precise quantitative analysis of the 3D geometry of the MA.

Late outcome after repair of mitral valve rupture during balloon atrial septostomy in a neonate.

Balloon atrial septostomy is ordinarily a safe palliative procedure for cyanotic congenital heart disease; however, if echocardiographic guidance is unavailable and fluoroscopy is used, distortions in the cardiac anatomy can invalidate the usual landmarks. Herein, we report iatrogenic mitral papillary muscle rupture during balloon atrial septostomy in a 4-day-old male neonate with total anomalous connection of the pulmonary veins. The anomalous connection and severe mitral regurgitation were emergently corrected, and the patient grew and developed normally. At age 24 years, he had only mild residual mitral regurgitation and was in New York Heart Association functional class I.In addition to describing the surgical treatment and positive late outcome of a rare complication, we highlight the importance of accurately evaluating balloon catheter location during atrial septostomy, especially in patients with a small left atrium.

Left ventricular pseudoaneurysm due to embolic myocardial infarction in infective endocarditis: real time three-dimensional transesophageal echocardiographic evaluation.

We report a case of a 63-year-old woman who presented with infective endocarditis and developed a pseudoaneurysm (PA) of the left ventricle presumably as a result of an embolic infarct. The diagnosis was made by typical features of PA on tranesophageal echocardiography and color Doppler studies. In addition, three-dimensional transesophageal echocardiography showed the narrow neck of the PA. Findings were confirmed at surgery and she was discharged after successful repair.

Ostial left main stenosis due to takayasu arteritis: multimodality imaging and surgical ostioplasty.

Takayasu's arteritis is an inflammatory process, involving larger blood vessels-namely the aorta and its branches. The majority of these patients present with symptoms of vascular obstruction. We report a case of a 38-year-old Chinese female who presented with one month history of angina pectoris as the initial manifestation. Coronary angiography showed 99% ostial left main coronary stenosis. The diagnosis was first suspected in the operating room by TEE and subsequently supported by laboratory studies and aortic biopsy. The technique of myocardial revascularization was altered and she underwent patch ostioplasty of the left main coronary artery and aortic valve repair to correct aortic regurgitation.

Real time three-dimensional transesophageal echocardiographic evaluation of a sinus venosus atrial septal defect.

We present a case of a 65-year-old man who presented with atrial flutter and dilation of right heart was noted on transthoracic echocardiography. Transesophageal echocardiography revealed a large sinus venosus atrial septal defect close to superior vena cava and anomalous connection of right superior pulmonary vein. Additionally, real time three-dimensional transesophageal echocardiography provided superior spatial details and demonstrated the size, location of the defect and its spatial relationship to the surrounding structures. Patient underwent successful surgical repair.

Practical guide for three-dimensional transthoracic echocardiography using a fully sampled matrix array transducer.

Real-time three-dimensional (3D) echocardiography is a major innovation in the history of cardiovascular ultrasound. Advances in computer and transducer technologies, especially the fully-sampled matrix array transducer, have permitted real-time 3D image acquisition and display. Several vendors provide 3D imaging but use different terminology for similar functions, creating confusion for consumers. This article provides a practical guide on how to acquire and analyze 3D images on-cart using currently available ultrasound systems (iE33, Philips Medical System, Andover, MA; Vivid7, GE Healthcare, Wauwatosa, WI) in daily clinical practice.

Aortic valve replacement improves survival in severe aortic stenosis associated with severe pulmonary hypertension.

BACKGROUND: Severe pulmonary arterial hypertension in patients with severe aortic stenosis (AS) carries a poor prognosis. There are limited data on the effect of aortic valve replacement (AVR) in these patients. METHODS: Our echocardiographic database between 1993 and 2003 was searched for patients with severe AS defined as a Doppler estimated aortic valve area of 0.8 cm2 or less and severe pulmonary hypertension defined as a pulmonary arterial systolic pressure 60 mm Hg or greater. Of the 740 patients with severe AS, 119 (16%) had severe pulmonary hypertension forming the study cohort. The AVR was performed in 36 (30%) of these patients. Survival of patients with and without AVR were compared and adjusted for comorbidities and group differences using the Cox regression model. RESULTS: Characteristics of patients with severe pulmonary hypertension; age 75 +/- 13 years, 39% women, left ventricular ejection fraction 41 +/- 20%. Patients who underwent AVR had a significantly higher five-year survival of 65% compared with 20% for those treated medically (p < 0.0001). The relative mortality risk associated with AVR was 0.28 (95% confidence interval 0.22 to 0.36) and was independent of age, gender, ejection fraction, diabetes, coronary disease, serum creatinine level, and concomitant medical therapy such as beta blockers, angiotensin converting inhibitors, and statins. The benefit of AVR was further supported by sensitivity and propensity score analyses. Patients on conservative therapy had a 30-day mortality of 30% and a one-year mortality of 70%. CONCLUSIONS: Aortic valve replacement in patients with severe pulmonary hypertension secondary to severe AS is associated with a huge survival benefit. Medical therapy alone carries a dismal prognosis and AVR should be considered urgently in severe AS patients with severe pulmonary hypertension.

Clinical profile and natural history of 453 nonsurgically managed patients with severe aortic stenosis.

BACKGROUND: Severe aortic stenosis (AS) is a surgically correctable condition. However, aortic valve replacement (AVR) is not offered to many patients with severe AS for various reasons. We investigated the profile and survival patterns of patients with severe AS who did not have AVR. METHODS: Our echocardiographic database was screened for patients with severe AS, defined as a Doppler estimated aortic valve area of 0.8 cm2 or less between 1993 and 2003. Seven hundred and forty patients with severe AS were identified, of whom 453 patients had no AVR through the follow-up period, forming the study cohort. These patients were comprehensively characterized by obtaining clinical, pharmacologic, and surgical data through a comprehensive chart review and extracting survival data from the National Death Index. RESULTS: Patient characteristics were as follows: age 75 +/- 13 years, 48% male, left ventricular (LV) ejection fraction 52 +/- 21%, coronary artery disease in 34%, hypertension in 35%, serum creatinine level greater than 2 mg/dL in 11%, and diabetes mellitus in 14%. The survival at 1 year, 5 years, and 10 years was 62%, 32%, and 18%, respectively. The univariate predictors of reduced survival were advanced age, low LV ejection fraction, heart failure, elevated serum creatinine level, severe mitral regurgitation, and pulmonary hypertension; and the independent predictors were advanced age, low LV ejection fraction, heart failure, elevated serum creatinine level, and systemic hypertension. Concomitant pharmacotherapy had no impact on survival. CONCLUSIONS: Conservatively treated patients with severe AS have a grave prognosis, and it is worse in the presence of advanced age, LV dysfunction, heart failure, and renal failure.

Malignant natural history of asymptomatic severe aortic stenosis: benefit of aortic valve replacement.

BACKGROUND: Patients with asymptomatic severe aortic stenosis (AS) are reported to have a benign prognosis and hence the American College of Cardiology/American Heart Association guidelines do not recommend aortic valve replacement (AVR) for patients with isolated asymptomatic severe AS. However, symptoms are subjective and would depend upon patient's life style. We examined the natural and unnatural history of initially asymptomatic patients with severe AS. METHODS: A search of our echocardiographic database between 1993 and 2003 yielded 740 patients with severe AS defined as aortic valve area 0.8 cm2 or less. Thorough chart reviews were conducted to collect clinical and pharmacologic data. Of these, 338 patients were asymptomatic at the initial encounter forming the study cohort. RESULTS: Patient characteristics were the following: age 71 +/- 15 years, males 51%, aortic valve area 0.72 +/- 0.17 cm2, left ventricular ejection fraction 0.59 +/- 0.17. Ninety-nine (29%) patients had AVR during a mean follow-up of 3.5 years. Survival at 1, 2, and 5 years in the nonoperated patients were 67%, 56%, and 38%, respectively, compared with 94%, 93%, and 90% in those who underwent AVR (p < 0.0001). The Cox regression model was used to adjust for the effect of 18 clinical, echocardiographic, and pharmacologic variables on survival. The adjusted hazard ratio for death with AVR was 0.17 (95% confidence interval [CI] 0.10 to 0.29). In the nonoperated group, renal insufficiency (risk ratio [RR] 3.1, 95% CI 1.5 to 6.6), beta blocker use (RR 0.52, 95% CI 0.31 to 0.88), statin use (RR 0.52, 95% CI 0.27 to 0.99), age (per year RR 1.03, 95% CI 1.02 to 1.05), and left ventricular ejection fraction (per % RR 0.99, 95% CI 0.98 to 1.00) were found to be the independent predictors of mortality. The benefit of AVR was further supported by sensitivity and propensity score analyses. CONCLUSIONS: Our observational data indicate that the natural history of asymptomatic AS is not benign and that survival is dramatically improved by AVR. Survival of the asymptomatic unoperated or nonoperable patients may potentially be improved by the use of beta blockers and statins.

Survival in elderly patients with severe aortic stenosis is dramatically improved by aortic valve replacement: Results from a cohort of 277 patients aged > or =80 years.

BACKGROUND: Calcific aortic stenosis (AS) is a disease of the elderly. However, there is reluctance to offer aortic valve replacement (AVR) for elderly patients with severe AS. We investigated if AVR confers a survival benefit in elderly patients with severe AS. METHODS: We screened our echocardiographic database from 1993 to 2003 for patients with severe AS (AV area < or = 0.8 cm2) and age > or =80 years. Two hundred and seventy seven patients were identified. Complete chart reviews were performed for clinical data. Mortality data were obtained from National Death Index. Survival curves of patients who underwent AVR during the follow-up period were compared with those managed nonsurgically. RESULTS: Patient characteristics were as follows: age 85+/-4 years, 53% male, AV area 0.68+/-0.16 cm2, EF 52+/-20%, CAD 47%, diabetes 17%. Over a mean follow-up of 2.5 years, 55 (20%) had AVR and there were 175 deaths. One-year, 2-year and 5-year survival rates among patients with AVR were 87, 78 and 68% respectively, compared with 52, 40 and 22%, respectively, in those who had no AVR (p < 0.0001). Hazard ratio for death with AVR adjusted for 19 covariates including age, EF, gender, comorbidities and pharmacotherapy was 0.38 (95% CI 0.26-0.66, p < 0.0001). CONCLUSION: Prognosis of medically managed severe calcific AS in the elderly patients is dismal. AVR appears to improve survival of these patients and should be strongly considered in the absence of other major comorbidities.

Mitral regurgitation progression following isolated coronary artery bypass surgery: frequency, risk factors, and potential prevention strategies.

BACKGROUND: Though de novo mitral regurgitation (MR) is frequently seen in patients who have undergone coronary artery bypass surgery (CABG), its incidence, predictors, and mechanisms are not known. METHODS: Our surgical registry was screened for patients undergoing isolated CABG who had preoperative and postoperative resting echocardiograms performed at our institution with